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Home My WebLink About040-1055-95-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and (3uil, Division INSPECTION REPORT Sanitary Permit No: 515071 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Sveiven, Terry I Troy, Town of 040 - 1055 -95 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: / VA� I 14.28.19.2168 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 3, /6 .5 V. Dosing Alt. BM �. � � Bldg. Sewer Holding StJHt Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing ` 5 ( Header /Man. Aeration `! Dist. Pipe '75-5-5 ? Holding Bot. System Final Grade 17A /, U PUMP /SIPHON INFORMATION 3 �P c � c 7 - ' Manufacturer Demand St Cover GPM Model Number TDH Lift Friction s System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS l05 -L _re ---, SETBACK SYSTEM TO P/L BLDG , IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION // CHAMBER OR Typ Of ` W�fd UNIT Model Number: 60" Q DISTRIBUTION SYSTEM (0 —A 0 (— j Header /Manifold. // Distribution x Hole Size x Hole Spacing Ve )o Air Intake] Dia Pipe(s) Length Length ` Dia \ Spacing J n4L, SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes ® No y es E] No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 723 Glover Road River Falls, WWII 54022 (NE 114 S 1/4 14 T28 R19W) metes & bounds Lot Parcel No: 14.28.19 16B 1.) Alt BM Description kJtJ �v�- �G -��G� L✓l�f�r 2.) Bldg sewer length = X� � - amount of cover = � � 's e, ,�,�, ✓Q,(' � 3 �1. 1.�� Plan revision Required? EJ Yes Vo G / Use other side for additional information. Date Insepc s Signatur Cert. No. SBD -6710 (R.3/97) Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 S .4 , �sconsin / M adison, WI 53707 — 7162 Sanitary permit Number (to be filled in by Co.) Department of Commerce (608) 266 -3151 5 f5 n '7 Sanitary Permit Application State Plan I.D. Number In accord with Gomm 83.21, Wis. Adm. Code, personal informati maybe used for secondary purposes Privacy Law, sl5.04 l� Project Address (if different than mailing address) I. Application Information —Please riot All Informak+ia� cEM i 7 �3 / / J e,,, Property Owner's Name � GF+ Parcel # Lot # B1L l.% # 77_rf `Ve SUN 0 C YC _/ j;6 ._qS% 000 Property� -f er's Mailing Address ST GFIM COUNTY Property Location / Z1 (0(Z B. / (:� t3 ve g- �� PLANNING & ZONING OFFICE ( V City, State Zip Code Phone Number �� °' `$ °• Section R IV e /Z /' /} j�S ivl- 5 VO Z 2 — circle o ) II. Type of Building (check all that apply) T ZA N; R(¢ E q W or 2 Family Dwelling - Number of Bedrooms Ap i Subdivision Name CSM Number ❑ Public/Commercial - Describe Use ❑ State Owned - Describe Use t 'j/ ❑City_❑Village PTownship of I fCl III. Type of Permit: (Check only one box on line A. Cdmplete line B if applicable) A. New System Repl acement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner 2 % , r ;2- /9 1 IV. Xpe of POWTS System: fCheck all that a 1 Non - Press urized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ R - ulating ilter ❑ Recirculating Synthetic Media Fitter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. DispersaVrreaWent Area Information: Design Flow (gpd) Design Soil Application f) Dispersal) ,, Area (s Dispersal Am Proposed osed ( Syste E VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Teaks Tanks Septic or Holding Tank n C � d® � /65(? n'(r�uJ'C.iZ - {l <Get3 X Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement - I, the undersigned, assume res onsibllity for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's S mat ber Business Phone Number he4 44et- 19. l< +L�e� �l °- 3 - � 38 ?is' zs -6 zuJ Plumber's Address (Street, City, State, Zip Code) VIII. County/Department Use Onl ved ❑ sapproved�Y Pamir F e (includes Groundwater Date Issuing Ag ngnature o s) Surcharge Fee) 4,47 � 3 ven Reason for Denial iX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: 1. Septic tank, effluent filter and �_ dispersal cell must all be services / maintained d� i �JJ' ^) ez, �G as per management plan provided by plumber. 2. All setback requirements must be maintained 11• • as per applicable Cade / ordinances. Attach complete plans (to the County only the system on paper not kss than 81/2 z 11 inches in sit SBD -6398 R.01 /03 / 7, Moe cot/A "4r �y N�1 r sWA S ty 1- 48 N R184J O Ott St 17 po k ASS C4 P {a tr#7 trrvt $- Act` -5 r,44 Ltc P ?err/ 5 veer ve r�J 12rv�� F.��fs �•,!� ! rgir ,v�`.� , sGa/y, S TzB RittW I �se, - � $t +t� ro w.._..�' qot cA 0 Fro frl-7 L.N4 x ALA` Scsr4 q3 3cgq SEPTIC TANK E' PUMP CHAMBE CROSS SECTION AND SPECIFICATIONS WEATHER PROOF JUNCTION BOX APPROVED k y ' WITH CONDUIT MANHOLE:"COV FINISHED GRADE W�. PADLOC l, WARNING';.L 18" IN. 6" MAX. NLET WATER TIGHT SEALS GAS- TIGHT1 , v 4" A SEAL APPROVED. CI PIPE —�-- , ALM JOINTS :..W TC 3' ONTO B i ON PIPE'3�..ONT SOLID _� t 5rm4 C9N I I 4x^ SOLID� SOIL C PUMP OFF ELEV .�,L'',F'T;' •- --- f0eo OFF fry RISER:-=EX D PERMITTED O: � IF:' TANK4 MANUFACTURE'. HAS APPROVA. 3" APPROVED BEDDING UNDER TANK 1 CONCRETE PAD P SPECIFICATIONS SEPTI / DOSE TANK MANUFACTURER: ° �rTJr��P #Sf NUMBER DOSES PER DAY: TAN SIZES SEPTIC JDv e, 4 DOSE VOLUME INCLUDING DOSE -- ems -0 FLOWBACK! GAL. ALARM MANUFACTURER: x� CAPACITIES: A = 2 INCHES = MODEL NUMBER: SWITCH TYPE: - -- -V .B = 2 INCHES PUMP MANUFACTURER: ._..0 C = INCHES = /1 SAL MODEL NUMBER; __ of d SWITCH TYPE: _ f 0��$ D = ' I INCHES _ .q1. REQUIRED DISCHARGE RATE 2 S GPM PUMP E ALARM WIRING AS PER ILHR 16.23V VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE CI - M 1 �t - �N Jai O FEET + M � .�.Q s.5. A.S` .FEET: + F — _ EET FORCEMAIN X (.3 FT /100.FT. FRICTION FACT OR F EET fin„ . � a � : TOTAL DYNAMIC HEAD = !FEET. LNTERNAL DIMENSIONS OF PUMP TANK: LENGTH ; WIDTH ; DIAMETER LIQUID DEPTH 5c 36 '� TG NED: c G am~ LICENSE NUMBER: i a� DATE: ?/88 r - 'ITT GOULDS PUMPS Wastewater PERFORMANCE RATINGS COMPONENTS Total Head Gallons Per (it. of water) Minute No Description EPO4 EP05 1 Impeller } 5 53 — 2 Base 10 46 62 3 Pump Casing 8 15 36 55 4 Mechanical Seal 20 21 46 5 Ball Bearings 6 25 0 33 6 0 -Rings 9 30 — 11 7 Power Cord 5 -- — i 8 Oil Filled Motor 4 Motor Housing/ 3 g Stator Assembly 1 10 Motor Cover METERS FEET 10 9 30 s GPNI 8 2.5 FT 25 p 7 a W 6 20 Q Z 5 0 15 4 EP05 O A � 3 10 EPO4 2 p 1 5 0 0 10 20 30 40 50 GPM 0 2 4 6 8 10 12 m CAPACITY 3 / L The Sin!Tech filter. with its unique design and mounting location, adowc ttw filtawring ccr"n to hss ccrubbrad whlla in operation. providing maximum maintenance intervals witfi unmatched performance capabiities. This fill su &arn & a gyp* 347 staknivss steel with .062 diameter holm k is 3 inches in diameter and 18 inches long with a 69.52 square inch open area This Marge 41% open area allows the filter to pass 83.8 gallons per minute at 1 psi. With features We these evrn a partially clogged screen wiN keep the system w N protected and working property. This preformance product assures quality effluent Wth lovar TSS i6wis. keeping your pressurized system functioning at 100% efficiency. Engineers and designers now have the ability to offer a simple safeguard. to assure systems wig function as designed now and In the future. The SknlTech filter can be used in both residential and commercial N applications. Fah W latt w titdIf slit -ter: 00.672 D� 1 P51 STF -lOOA2 Flow rate w 9s ° o pli ed screen. dA.912 GPD IS P51 t:oaxnerdal /nanffoAd Total head lossr` or .2l P51 asst M i www.gag- sitnt6ch.COM $88- 999 - 3294 s1Mt6chGft6way 04/30/09 THU 16:02 FAX 715 386 4686 ST CRX CO ZONING 004 "isconso,Department of Industry SOIL AND SITE EVALUATION Labor and•Human Relations Page I of 0 - wimon of8afety and Buildings in accordance with s. ILHR 83A is. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County 1 /� include, but not limited to: vertical and horizontal reference point (BM), direction and S' + C Iro t X percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information ou provide may be used for seconda` r u ( y d) ( )) Y F Y �p rposes HFivac Law, s. 15.04 1 m , Property Owner (� Property Location Q r r V 2 I (I 1'1 t.Jo,In.- W �. � ca , Govt. Lot 1 /4�SU 1/4,S L y ,T 2,5 ,N,Ft 9((or) W Property,Owner's Wiling Address Lot # Blo6k* - ,_ Subd. Name or CSM# "7 2 3 (, l a J e.2 o City State Zip Code Phone Number ❑ cit ❑ villa Town Nearest Road �( r-o` (71ou.er ❑ New Construction use: ❑ Residential / Number of bedrooms "1 S t7 Addition to existing building 'Replacement ❑ Publiaor commercial Describe: Code derived daily flow ` 7So gpd - Recommended design loading rate 0, -7 bed, gpd/ft trench, gpd/ft Absorption area required L 4 43 bed, ft S -trench, ft2 Maximum design loading rate b -7 bed, gpd/ft O • g trench, gpd /f1 Recommended infiltration surface elevation(s) 7 (ID ft (as referred to site plan benchmark) Additional design /site considerations h 1 Parent material __ GS �t d C W c.s Flood plain elevation, if applicable ft S Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U unsuitable for system ❑ ❑ U ❑ S ❑ U ❑ s El EIS [J u ❑ S ❑ U ❑ S ❑ U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft Texture Consistence Boundary Roots in. Munsel! Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench >v Y R 3 i Q z F s6k s S -{' o. ; 0• s x t,� 2 ► -�� Ground 3 2y 33 /o /Z s" / ^ S a s9 a/ as o.T o.$ elev. la, on. c / 55.5 /d 4 4/ Co 3 6 - 7. O, 8 Depth to -� sb. jo R S� v s O s GQ �-'° 0.7 ' O limiting factgr , 7 in. Remarks: Boring # 15-13 10 2 3l) ,Q �FS6lC d s S .3 V-S' (3 _ 3 3 to y2 4113 l 0. 5' 0.6 o Ground `4, L' Depth to limiting ` �' S� A GE I-ab—in. Remarks: CST Name (Please Print) Signature £ lep�h /one No I 'l So -k Address Date CST Number L4 �3D. IaO l S-�' , Yle"� ;C_krNo.,CD Lit I0 19 -q cstw, 0)-40 04/30/09 THU 16:03 FAX 715 386 4686 ST CRX CO ZONING Q006 PhOPERTN OWNER SOIL DESCRIPTION REPORT Page Z al. . 3 PARCEL LD.# Boring #. Horizon. Depth Dominant Color Mottles Structure 2 Texture Consistence Boundary Roots M` • -•. - in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. <` Bed Trench % •''•; Ste:'. a V o -I � fL3 ! � �'SG k .oPS 3 �s,� G,r 2 s"� 1F aos a Ground 3 /v Q s i __ �° O S C� •C d. 018 elev. 31 - 1OVit- 3 Depth to • $ /d 2 59 J� V(� s� limiting factor in. Remarks: Boring # PiWIN Ground elev. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Structure GPD1tr Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench boring .# s< ON ' Ground elev. tt. ' Depth to limiting , factor in. Remarks: Boring # , iv,: s: Ground elev. ft. , Depth to limiting factor in. Remarks: SB -8330 (R. 08195) 04/30/09 THU 16:03 FAX 715 386 4686 ST CRX CO ZONING 005 Voj, of 3 . 'e-r o I 1 0 W I'1 X3 F J 3 c cQ r n At-4c 2 q' � � t o . 4tp` 2. QA C, r2 P0,rcc,� � � t 4� 57, i �bS q r Q►Yl /� S�oue p`�e Wr weer I.:,� �., ce"�er r p oP 54 - 00q p. tnJ w c � I a 110 {,AIL O lleht 7i�2 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer a 1 -1f ye (ve.J Mailing Address - /;2--3 (5 t o ✓ et- P -0 u e :c F.g %/s wr gc/a z Z Property Address (Verification required from Planning & Zoning Department for new construction.) City /State Ri de F�(�S /� Parcel Identification Number LEGAL DESCRIPTION Property Location A19 1 /4 , $ Gc) 1 /4 , Sec., T 2 N R_/yW, Town of _ goy Subdivision , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 66 70 d `I , Volume % a 7 q , Page # 0 5 2 Spec house yes no Lot lines identifiable Des SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the r e Department of Natural Resources standards set forth, herein, as set by the Department of Commerce and th p , State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I /we certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Numbe of b rooms 3 SIGNATURE OF AP PLICANT(S) DATE ***Any P information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** I Include survey ma if d with this application a recorded warranty deed from the Register of Deeds Office and a co of the y p nclu e app ty g copy reference is made in the warranty deed. (REV. 08105) DOCUMENT NO. I — TRU IIeEED ur'6 7 1 Y�L �. 0 4 ?AGE . Donna J. Wilcoxson and Williau A. Owvuz as Co- Trustees of Donald D. jI and X. June cmmus >remily. Tru3t. for a valuable consideration conveys to Yarrp X. $voivan and Xatbloon K. sveivcn, husband and w.ife, the �I `ollowing described real eotate in St. Croix County, state of Wisconsin . �.: The North 420 feet of West 2iO feet of the Northeast Quarter of ST, � ' "E f�:r WI � Southwest Quarter (NE 1/4 of SW 1/4) of Section Fourteen (14), Township t ? " Twenty Eight (28) North, Range Nineteen () est, St. Croix Caanty, Wisconsin. 19 W ACT j I9Q7 11:15 I� � *& c A I I NAME AND P.$TURN PJ) &E SS._'_ t $ T AN FER fi�� 040 - 1055 -95 Parcel Idei;tic- n Namber (PIN) Dated this ? 5! -{- day of October, 1591. T L, -`l __(SEAL) �, /± / Dv:*ut uooxson, Co '^ �. ` r <.rL •E ^ (SEA?,) W�1]�am A. Owens, Co Trustee AUTHENT I Ci►3I uX ACKN0NXMX iI Wr Signature(s) _ STATE OF WISCONSIN ) St. Croix. ) ss. — authenticate this _ day of i9 covlrrY ) � Personally came before me this M f October, 1997, the above named Donno J Nilcoxson and William A. Owenn to m2 known to be the person(s) who executed the foregoing instruirent and acknowledge -- - -- the s TITLEt MEMBER STATE BAR OF WISCONSIN (If not. authorized by §706.06, Wis. Stats.) + Virginia R. Gart THIS THSTRi3l1"i.IIT WAS DRAFTED By: tdotary Public St Leo A. Beskar, Attorney _ Cr n � ; County, Wis. kODLI, BESKAR, BOLES & KRUEGER, S.C. My COPTrdZ - ion is permanent. (If zot, expiratico date: 219 North Main Street, P. O. Box 138 R $� _ T�n(t�rk River Falls, WI 54022 iC� �� / 2 0() 0 ) �9 �j01 F . - OCT -31 -1997 08:49 INDEPENDENCE MORTGAGE,INC 612 702 9449 P.02/03 STC - AS D1JIL'r SANXTARY SYSTEX RFPORT OWNER Tf s AD UREs S 3 1 v e le d. SUBDZVZSION / CSMI LOT SECTION L Town of 6 ST CROIX COUNTY, WZSCONSYN SHOW EVERYTHING WXTHZN 2.00 FEET OF SYSTEM Moo V h tom O INOICA7TE NORTH ARROW Provide setback and elevation information on reverse o Provide d - f this form. >�mensions to Cent of septic tank manhole cover. OCT -31 -1997 08:49 INDEPENDENCE MORTGAGE,INC 612 702 9449 P.03/03 A.LTBRNATE I3H SEPTIC iC / POMP / MOLDING TANK INFORMAT'lON Manufacturer: If Liqu Capacity: 14W � W Setback from: Well � Other Pu =p; M anufacturer �f Float seperation f� Gallons/ G cle: �! r Alamo Location C ti S(]IL AS$ORPTIOx SYSTEM 2 !f r r Width: J Leh9�tR (� Number of trenches �ij r fIY��Or Distance fi, Directi to nearest prop. line: ey r -- c Setback from: well..- House Other ELEVATIONS Building Sever ST Inlet: ST cutlet: PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade _ Final grade OATe OF INSTALLATIO = �v d 9 PWNBER ON JOB: LICENS NUMBER s a 31 rNS PECTOR _ Q_. 3/93 : j t TOTAL P.03 Wiscom n Department of Industry PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 299129 Permit Holder's Name: ❑ City ❑ Village t Town of: State Plan ID No.: OWENS TRUST (DONNA WILCOXSON) TROY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 040 - 1055 -95 -000 TANK INFORMATION ELEVATION DATA A9700446 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic j S cr r� ��Pt r'z. <, / J Benchmark /�S ZZ S, _71)� /&b. Gd Dosing %,ce; (c' Aeration Bldg. Sewer /0,0 e7 ZS Holding St /0 Inlet /',0 3,%7 TANK SETBACK INFORMATION St /Ht Outlet TANK TO P / L WELL BLDG. Air I ntake ROAD Dt Inlet ir ' Septic ' /74 NA Dt Bottom 29 2 Dosing 'f v�3 ' NA Header / Man. �, �g % 57 9 7, Y Aeration NA Dist. Pipe Holdin g Bot. System (jk �' 9,79 q PUMP/ SIPHON INFORMATION Final Grade Manufacturer �� emand ~' S /I'1� 2�S ( 16)0 Model Number 6 7 0 y , W / L9 f p GPM //�� y �y Ce Lt: in TDH Li Friction System P TDH Ft oss Head Forcemain ength I,4_ Dia. Z Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length No. Of?T-rrenches PI EN 1 N No. Of Pits Inside Dia. Liquid Depth DIMENSION ACHIN Manuf cty�er: SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM h f j — a-�V ✓ INFORMATION Type ; 1 CHAMB Mod I um er: 1�'�.� /` I T s System: 7 DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 14.28.19.216B,NE,SW 723 GLOVER ROAD ir 1, Plan revision required? f ❑ Ye ❑ No Use other side for additi�Qal ' ormation. SBD -6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH , SANITARY PERMIT NUMBER: E s E , - . A t F x a r , I I OCT -31 -1997 08:48 INDEPENDENCE MORTGAGE,INC 612 702 9449 P.01iO3 hl0RTGAGE FR oAf; 612 NO. 01 — 1)Is,S'Cl?II'l70N CAF 1)0C ;S/COAfA?1,N7:S: It r i+ I, II M S I) S 1 � t E GOVERNMENT CENTER 1101 CARMICHAEL ROAD HUDSON WI 54016 D=: TO= FAx = boa — 9 NAME= FAX : (715) 386 -4686 NAME: NUMB OF PAGES ]ZKXMM OOM SBEET: b PL EASE CT: CATION IS NOT RECEIVED, p TEUWEMM NUMBER: �ACTz P l• l• ST. CROIX COUNTY . , s WISCONSIN 1 =� ZONING OFFICE ° " " ""u ■ u ■�..� ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road - _ Hudson WI 54016 -7710 (715) 386 -4680 I� October 30, 1997 Independence Mortgage Attn: Mary Ann 1800 Wooddale Drive Woodbury, MN 55125 RE: Septic Inspection for Owens Trust /Donna Wilcoxson located at 723 Glover Road, River Falls, St. Croix County, Wisconsin Dear Mary Ann: An septic inspection of the above referenced property was conducted on October 29, 1997. This property is located in the NEY of the SW of Section 14, T28N -R19W, Town of Troy, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3) bedroom home. If you have any questions regarding this, please contact our office at (715) 386 - 4680. Since ely, e Thomp n Zoning Specialist sm ,.' SANITARY PERMIT APPLICATION 2 01 e E.W and shn `�SC011S�I1 P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 vi x 11 inches in size. �ro� • See reverse side for instructions for completing this application state s The information you provide may be used by other government agency programs (3 Check i( revision to prev us application IPrivacy Law, s. 15.04 (1) (m)). State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property Owner Name 61tj &f P�opert Location S �nJ2tf � Zia, S �S T p , N, R V(or) W Property Own is 77 Address Lot Number Block Numb Q [Cd. State / �� Zip d d �d Phone N� Subdivision Name or CSM Number 11. TYPE OF BUILDING: (check one) ❑ State Ow ned ❑ It� Near % st Clad ❑ vil age J Public 1 or 2 Family Dwelling - No. of bedrooms o To FT&4 6 6U� 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number (S 1 [] Apartment / Condo NZ 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT (Check ly one box on line A. Check box online B, if applicable) A) 1. E] New 2. eplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ E] Repair of an System System_ Tank Only______________ Existing System - --------- Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 []Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 E] System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 17. Final Grade Re ulr ft.) Propose s . ft.) (Gals) a / ft. ( in.Anch) /� Elevation 115, q p y .7� b Feet Feet TANK Capacit VII. INFORMATION in gallon Total # of Manufacturer's Name Prefab. it steel Fiber- Plastic Exper. New Existing Gallons Tank concrete structed glass App. Tanks Tanks 12 1 Septic Tank or Holding Tank J� S ❑ 11 11 11 11 Lift Pump Tank /Siphon Chamber ❑ 1 ❑ ❑ I ❑ I ❑ ❑ Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility or installation of the onsite sew shown on the attached plans. yj, uffl ber's Name: (Print) rm is Signature: o to ps) Business Phone N ber �A k Plumber's Acdr r t, city, S Co ` D t ^� C # , ' SA O IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved S itary Permit Fee (includes Groundwater Date I ssued Issuing Ag nt Si ps) Surcharge Pee) / AXI p "' p , ricived E] Owner Given Initial / �)d 00� Adverse Determination / X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 IRA 1/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber A INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. , 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608- 266 -3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III_ Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7_ VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. i Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. r ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated_ practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. i 73 �1 s s 4AI e New t s�, 4g� LGr e b ^ b ' Jhd�b��P�ch�s d T l � 7'0 2" DIM 3 T o � r Aldo Wisconsirx Department of Industry SOIL AND SITE EVALUATION Labor and Human Relations Page l of bivi §ion of'Safety and Buildings in accordance with s. ILHR 83.0 ",!S. Adm. Code ' Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County /� include, but not limited to: vertical and horizontal reference point (BM), direction and S 4 C r 0 t x percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondar urposes (130vacy Law, s. 15.04 (1) (m)). f Property Owner Property Location Q r r V e t V C h �)ovin..- W ( Loy, Govt. Lot Ic 1 /4•.3W 1 /4,S y T 28 ,N,R V(or) W Property Owner's Wiling Address Lot # Block* Subd. Name or CSM# '72 or- City State Zip Code Phone Number City ❑ Village Town Nearest Road r-o 6 ❑ New Construction Use: ❑ Residential / Number of bedrooms U Addition to existing building 'Replacement , ❑ Public or commercial - Describe: Code derived daily flow t� ` S o gpd / Recommended design loading rate 0 • bed, gpd/ft a trench, gpd/ft / Absorption area required Coll 3 bed, ft S63 trrench, ft Maximum design loading rate 0.1 bed, gpd/ft g' g trench, gpd/t Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design /site considerations r� Parent material `R C i <' r.uc.si') Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure I AT -Grade System in Fill Holding Tank U = Unsuitable for system ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 0.5 2- 11 -2-j /0 2 y3 $ 11� fr 0.6 Ground /0 /L S /�' S 0 S9 CIO / a .S L ; �• elev. 100, oft, c/ 35-50 6 5 - 5 d / �S 6.7 O• $ Depth to s 50. /u 2 S"/ v , s 0 S C e/ O,- o $ limiting ; fact r 7�in. N Remarks: Boring # 0 -13 la Yfz. 311 ,� �FSG.I< d s S 3 F d.�/ o•S 2 13 -33 10 y2 WT — s �[ f s l o. S : 0.6 3 33-8 10 YiZ s e li 0.7 :0,9 Ground � el C e � v � Q Depth to G limiting �� ` '•t AGE fact r ® in. Remarks: e a CST Name (Please Print) Signature £ lephone No. �— 1r� � s �� •a ysy 1 ►z 3 rn55 1lt�Scn Address f n Date CST Number 1y l2v �1, S� , 1rle� � Li L 1a 19 -q'1 c5im 0)-405 PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z • 9 PARCEL I.D.# Bonn #. Horizon Depth Dominant Color Mottles Structure 2 Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench V o -1 / `L S// a r 5 6C oP S 3 rs. G,S Z !z -zz 0 vr a Ground 3 Q S oe S � elQ(z .,, t. y 2- 3 /O Y9- e s COP s Depth to J 3 - g /d t /Z S $ �� 6 S limiting 3 1 factor Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; Ground elev. ft. Depth to limiting factor ' Remarks: Boring # Ground elev. ft. , Depth to limiting factor in. Remarks: SBDW -8330 (R. 08/95) r, OCN^Cl �.1caKtn 0w n Shy lrvi �[ l0 Lc) X3 3 b c cQ ro o R Res c o o 2,9 I I� t 5 o 2 OACre. p0,rc.e� ' � t d $Z t Ln� Q g3 q A 94oue p1 f e. Wl wcAer nnc I r, Ce" er' Clap vF 5+00q, In.j w e. 1 I O dome kole d ue.h � ►�� STC -105 SEPTIC TANK MAINTENANCE AGREEMENT , St. Croix County OWNER/BUYER NO { MAILING ADDRESS PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY /STATE U PROPERTY LOCATION 1/4, 1/4, Section , T 40 N -R,4 TOWN OF ST. CROIX COUNTY, WI SUBDIVISION ---- LOT NUMBER r– CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER mproper use and maintenance of youur septidsyst m could re ulf ih its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration d te. SIGNED: JO 1 7 DATE: U St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 8 T C - 100 Thia'application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with, the appropriate deed recording. ------------------------------------------------------------------- Owner of property 61,v ( Location of property_ 1 /4� _1/4, iection I T N - R _ Township Mailing address 2. �� Address of site 2 ,� Subdivision name - ---�� Lot no. Other homes on property? Yes No Previous owner of property T ' , L]A' Total size of property Total size of parcel 9 tk C P s Date parcel was created Are all corners and lot lines identifiable? _Yes No Is this property being developed for (spec house) ? Yes No volume and Page Number ZA as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in a o9f ice of the County Register of Deeds as Document No. b , and that I (we) presently own the proposed site for the sew-age disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the 5��;3 of the County Register of Deeds as Document No. Signature of Appli ant Co Applicant Dabi S7iAfvatuxe natP of q;rtnati,rA Ov ' s STATE BAR OF WISCONSIN FORM 3 — 1982 QUIT CLAIM DEED DOCUMENT NO. ;� _.- �.�.�. -•+�� _— William A. Owens - 14.298; Donna J. Wilcoxson - 14.29 V-1 S7 CRO(X CO., W ilma J. Smith - 14.29$; Judy R. Nielsen- 14.29$; Joy D 1[w,+rINPAoaI R eis - 14.298; Rita M. Griffey- 14.298; Tamara J. He 7 .13%; and Mark W. Nelson-7.13% as tenants in comm OCT, 8 1996 s 1 quit - claims to Donald D. and M. June Owens FamilY at 10:00 A.M Trust, Donna J. Wilcoxson and William A. Owen & �� Co- Trustees, Joy D. Reis, 1st Alternative Ih�wrde having full power to sell and t �; Trustee, ' e ncumber 1 the following described real estate in St. Croix �! State of Wisconsin: �+ 1 !� MM/E AM RETURN ADDRESS 14Leo A. Beskar, Attorney RODLI, BESKAR, BOLES & KRUEGER 219 North Main Street P. O. Box 138 River Fails, WI 54022 �> nan_tnsi�— PARCEL IDENTIFICATI N NU11tiER j I The North 420 feet of the West 210 feet of the Northeast Quarter of the Southwest Quarter (NE 1/4 of SW 1/4) of Section Fourteen (14), Township Twenty Eight (28) North, Range Nineteen (19) West. EXIMPI i ii This _ _ i s no t homestead property. !]V[ (is not) i Dated this 30th d of August 19 _ 26 (SEAL) (SEAL) A liam A. s (SEAL) (SEAL) y R _ • cox n R a li Wi J. (SEAL) 4 .4e (SEAL) ( SEAL) •� ( SEAL) Jud a sen ar ^ s (.1 ±' AUTHENTICATION ACKNOWLEDGMENT it Si ture( s)Williaw A. Owc rls Donna J. Wilcoxsull, State of Wisconsin, �+ W� m J. Sit' th J d R. N e sen o e s, ss• ji R. rife a7iara Z: eru�n an Marc �f. Ne 1 s cor`n`y. !' au 30th A �, u u s t 19 prrsoxtall came before me this day of 19 , the above named i� �i I Leo A. Beskar TITLE: MEMBER STATE BAR OF WISCONSIN (if not, authorized by 3706.06, Wu. Slats.) to me known to be the person who executed the foregoing j instrument ad acknowledge the same. C THIS INSTRUMENT WAS DRAFTED BY G j Leo A. Beskar, Attorney RODLI, BESKAR, B LES & KRUEGER, S.C. • x e . O. BOX 138 Notary Public., County, Wu. �tt�t�i�s 3ufhen t ted or ac aw dged. Both are not My commission is permanent. (If not, state expiration date: necessary.) 'Names of persons s,gning in any capacity should by typed or pnnted below their signatures. I STATE 11AR OF WISCONSIN wilconxn Leo elr* Co , inc. QJIT CLAIM DEED Form No. 3 — 1982 M*.O k•e• Vft ST. CROIX COUNTY t WISCONSIN 0 ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmi Hudson, (71, 3 - 680 � SEPTIC INSPECTION / WATER TEST REQUE ORM S�P ' Please specify desired test(s) & remit appr iat ST 6 199 wit application. Outside water lines are often t duri n winter months, making access to the home necessa 3 Plea arrangements with this office to insure that entry ❑ Water (VOC's) $185.00 Septic $50.00 ❑ Water (Nitrate & Bacteria) 45.00 ❑ Nitrate & Bactria n Water (Lead Concentration) 21.00 retest $15.00 Owner _aeA4 ,/ j Requested by :,: :7a, Address: Address 757 ZIP Telephone Np: ( ) Telephone W: (�� Property address Fire W & street): Location: ;, ;, Sec. I , T — N, R -_W, Town of Realty firm: Lock Bo 0V � i Box Combo: Closing -- -e. TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM* Water sample tap location: Is the dwelling currently occupied.' ❑ Yes No If vacant, date last occupied. /p g( Age of septic system: Septic tank last pumped by: Date: 95� Previous Owner's Name(s): i Have any of the following been observed? ❑Y 911' Slow drainage from house. ❑Y Chi Sewage Back -up into dwelling. ❑Y ❑fI Sewage discharge to ground surface or road ditch. ❑Y Dff'_ Foul odors. Other comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. OWNERS SIGNATURE : ��L71/L./ /.[/'rte DATE: �� 97 OWNERS DRA ING OF HOUSE & SEPTIC SYSTEM LOCATION I . �1 ` TO BE COMPLETED BY INSPECTION AGENCY System design & /or permit on file? OYes ONo Soil series per SCS Soil Survey: sheet # Type of soil absorption system OBelow grd OAt -Grd OMound Approx. size 'X 0 OGravity ODose OPressurized Ft .2 OBed OTrench ODry Well Molding Tank 00utfall pipe OBSERVED DEFICIENCIES 00ther OUnknown Septic tank Setbacks: OHouse OWell OProp. line 00ther Dose tank Setbacks: OHouse OWe11 OProp. line OOther ❑Locking cover OWarninglabel OPump /Floats OAlarm OElec. wiring Soil Absorption System Setbacks: OHouse OWell OProp. line 00ther OPonding: ODischarge: General comments INSPECTORS SKETCH OF SYSTEM LOCATION Inspector __ Title ST. CROIX COUNTY WISCONSIN ZONING OFFICE I I HO I a ■ ,.., ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road µ _ -„- Hudson, WI 54016 -7710 -- (715) 386 -4680 September 30, 1997 Donna Wilcoxson 747 Glover Road River Falls, WI 54022 Dear Donna: On September 30, 1997, an inspection of the septic system on the property owned by the Owens Family Trust, located at 723 Glover Road, River Falls, Wisconsin, was done. At the time of the inspection, the sanitary system appeared to be functioning properly, however, it was indicated on the application that the residence has been vacated. Therefore, should this system be failing, it most likely would not be evident at this time. The inspection done was based on a surface inspection of the system, and did not involve any excavating or chemical analysis. Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system be pumped once every three years. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. Should you have any questions, please contact me at the above number. Sincerely, QVZ"� Mary J J�ins Assistant Zoning Administrator CC: File RECEIV ST. CROIX COUNTY ZONING OFFICE JUN 1 5 2009 CERTIFICATION STATEMENT PLANNING & ZONING OFFICE FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the —,— �� z3 �' j °`'�" residence located at: / C, /Y ,�/ S v Al f — 1 /4, 4L/ 1 /4, Section / �/ , Town 7-8 N, Range / W, Town of - � - �0 , St. Croix County Wisconsin. Upon inspection I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of service Z U C) 77 Did flow back occur from absorption system? Yes_ No (if no, skip next line.) Approximate volume or length of time: _�� gallons minutes Capacity: ov 6sz C?cfi,A�av Construction: Prefab Concrete Steel Other Manufacturer (if known): rare c "t-4 � Age of Tank (if known): 1 7 1 01,4.4 e& icensed Plumber Signature) (Print Name) (Title) (License Number) M /MPRS - j - ccti e /ova (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code)